COVID-19-associated Miller-Fischer syndrome: Difference between revisions
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===Primary Prevention=== | ===Primary Prevention=== | ||
Effective measures for the primary prevention of '''covid-19''' include handwashing, wearing of face masks, social distancing, avoidance of large gathering and self-isolation for patients who have mild symptoms. | Effective measures for the primary prevention of '''covid-19''' include handwashing, wearing of face masks, social distancing, avoidance of large gathering and self-isolation for patients who have mild symptoms. | ||
==References== | ==References== | ||
Revision as of 13:41, 11 July 2020
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COVID-19-associated Miller-Fischer syndrome On the Web |
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American Roentgen Ray Society Images of COVID-19-associated Miller-Fischer syndrome |
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Risk calculators and risk factors for COVID-19-associated Miller-Fischer syndrome |
Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1]; Associate Editor(s)-in-Chief: Template:ArashMoosavi
Synonyms and keywords:
Overview
Miller Fisher Syndrome (MFS) is an acute peripheral neuropathy which can develop after exposure to a viral or bacterial infection. It includes triad of ophtalmoplegia, areflexia and ataxia. In covid-19 pandemic period, while covid-19 typically presents with fever, SOB and respiratory symptoms, MFS with prior history of covid-19 has been seen in several cases all around the world.
One retrospective study in 214 patients has shown that 8.9 % of covid-19 patients have reported peripheral neurological symptoms.
Historical Perspective
The first reported case of MFS with history of covid-19 was detected on January 2020 in Shanghai, who was a middle-age woman diagnosed with MFS presented with areflexia, acute weakness in both legs and severe fatigue. Further reports were announced by medical groups in Spain and the USA which presented neuro-ophtalmological symptoms. [1]
Classification
MFS is a rare variant of Guillain-Barre syndrome, characterized by ophtalmoplegia, areflexia and ataxia.
Pathophysiology
MFS is related to dysfunction of third, forth and sixth cranial nerves. A typical serological finding in patients with MFS and prior history of covid-19 is antibodies against GQ1b ganglioside, though negative test for antibodies does not rule out the diagnosis. The presence of ophtalmoparesis in MFS is related to a action of anti-GQ1b antibodies on the neuromuscular junction between the cranial nerves and ocular muscle. ELISA test is positive in 70% to 90% of patients.[2]
Causes
Although MFS has been detected in some patients with covid-19, other viral and bacterial infections can also cause MFS
- Influenza virus
- Cytomegalovirus
- Zika virus
- Mycoplasma
- Campylobacter
Differentiating COVID-19-associated Miller-Fischer syndrome from other Diseases
MFS must be differentiated from other diseases that cause ophthalmoplegia, areflexia, and ataxia, such as myasthenia gravis, botulism, diphtheria, brain stem stroke, brain stem encephalitis and basal meningitis. It is essential to rule out emergent neurological disorders like stroke or brain injury in patients with MFS symptoms.[3]
Epidemiology and Demographics
While the incidence of MFS is one or two person per million each year, the prevalence of MFS associated with covid-19 is still unknown.
Risk Factors
There are no established risk factors for MFS associated with covid-19.
Screening
There is insufficient evidence to recommend routine screening for patients with MFS caused by covid-19.
Natural History, Complications, and Prognosis
There is an increased risk of death in patients over the age of 60 year-old. Hence, the mortality rate is estimated to be 3.6%.
Risk factors for severe illness and poor prognosis include:
- Old age
- Male gender
- Patients with
Diagnosis
Diagnostic Study of Choice
Although the diagnosis of covid-19 is based on respiratory symptoms, it can be associated with neurological symptoms, of which overlap the diagnosis of MFS. Consequently, in patient with prior history of covid-19, other neurologic diseases should be ruled out and anti-GQ1b antibody test should be considered. Also, in new patients with suspicious symptoms for covid-19 and neurological symptoms, nasal swab test and neurological examination should be considered.
MRI may be performed as a part of diagnostic work up. Although in majority of cases no abnormality is detected, enlargement and prominent enhacement in orbits and retro-orbital region has been reported in some cases.[4]. [5]
History and Symptoms
Symptoms of covid-19 associated with MFS include:
- Respiratory system symptoms
- Neurological symptoms
Physical Examination
Patients with covid-19 associated with MFS present various signs and symptoms related to systematic and neurological presentation. Hence physical examination should be performed based on signs and symptoms include:
Vitals
Abnormal signs associated with covid-19:
- Tachycardia
- Tachypnea
- Fever
neurological
- Eye dropping
- Blurry vision
- Paresthesia
- Decreased sensation
- Myalgia
- Weakness of breathing muscle
Laboratory Findings
Laboratory findings consistent with the diagnosis of covid-19 include positive PCR nasal swab.
Laboratory test for neurological signs are not diagnostic and should be used with other clinical parameters. They are include:
- Ganglioside (GM1) Antibodies, IgG and IgM
- GD1b Antibody, IgM
- GQ1b Antibody, IgG
Electrocardiogram
There are no ECG findings associated with covid-19.
X-ray
CXR is less sensitive in detection of covid-19 in comparison with CT. However, in some cases lung consolidation and patchy peripheral opacities corresponding to ground glass opacities has been reported.[7]
Echocardiography or Ultrasound
There are no echocardiography/ultrasound findings associated with covid-19.
Lung Ultrasound may be helpful in evaluation of patients with covid-19. It indicates :
- Multiple B-lines
- Ranging from focal to diffuse with spared areas
- Irregular and thickened pleural lines
- Subpleural consolidations
- Alveolar consolidations
- Bilateral A-lines
CT scan
The preliminary findings of CT in COVID-19 associated with MFS include:
- Bilateral Ground Glass Opacities
- Air space consolidation
- Bronchovascular thickening
- Traction bronchiectasis
MRI
Brain MRI may be helpful in the diagnosis of MFS in patients with prior history of covid-19 and neurological manifestations. Although there can be no abnormalities, multiple cranial nerve enhancement has been reported in some patients.
Other Diagnostic Studies
There are no other diagnostic studies associated with covid-19 with MFS manifestations.
Treatment
Medical Therapy
No specific treatment and vaccine exists for covid-19 yet. However, patients with moderate to severe ARDS and respiratory manifestations can benefit from Mechanical ventilation and extracorporeal membrane oxygenation (ECMO). In some patients the combination of antiviral therapies like protease inhibitors, ritonavir, and lopinavir indicated partial success in treatment of covid-19.
Remdesivir, a drug originally developed to treat Ebola virus, showed positive results against SARS-CoV-2.
Dexamethasone has been announced as an effective treatment in patients with systematic manifestations.
Surgery
Surgical intervention is not recommended for the management of covid-19.
Primary Prevention
Effective measures for the primary prevention of covid-19 include handwashing, wearing of face masks, social distancing, avoidance of large gathering and self-isolation for patients who have mild symptoms.
References
- ↑ Template:Gutierrez-Ortiz C, Mendez A, Rodrigo-Rey S, et al. Miller Fisher syndrome and polyneuritis cranialis in COVID-19. Neurology 2020; April 17. doi: 10.1212/WNL.0000000000009619
- ↑ Template:Https://pubmed.ncbi.nlm.nih.gov/10695710
- ↑ Template:Https://rarediseases.org/rare-diseases/miller-fisher-syndrome/
- ↑ Template:Http://www.ajnr.org/content/early/2020/05/28/ajnr.A6609
- ↑ Template:Https://rarediseases.org/rare-diseases/miller-fisher-syndrome/
- ↑ Template:Http://www.ajnr.org/content/early/2020/05/28/ajnr.A6609
- ↑ Template:Https://www.ncbi.nlm.nih.gov/pmc/articles/PMC7141645/